Within bundled payment programs and depending on the cost of care for an episode there may be: (a) an incentive paid to the healthcare system/provider, or. Good UI and UX of payment gateway. Because it is based on government regulation, it can be changed. Photo credit: Mosaic Medical. CPC+ will give the primary care provider - a physician practice, a clinic, or "medical home" - a set fee per month or year for each patient, which was the backbone of the controversial HMOs of the 1980s and 90s. (3) Care providers benefit from knowing the predictable amount they will get paid for patient care, even if the costs associated with that care are less than the agreed-upon bundle amount. Counties, Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes, Building Health and Resiliency: Philadelphias 11th Street Family Health Services, Building Partnerships to Improve Health in the Rural South: CareSouth Carolina, Transforming Care: Reimagining Rural Health Care. Payment reforms in entitlements have significantly altered the healthcare equation, as has the rise of managed care. Like FQHCs in Massachusetts, Providence Community Health Centers in Rhode Island is working under a state-led model to shift to APMs. Outreach campaigns to bring attributed-but-unseen Medicaid beneficiaries into primary care are notoriously unsuccessful. lock A Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. Without such supports, FQHCs may struggle to develop the data analytics and financial forecasting tools needed to predict the cost of caring for populations with complex medical and social needs. The authors say lower testing rates, greater disease severity at care presentation, socioeconomic factors, and racial discrimination all contribute to the observed disparities. Medicare's prospective payment system (PPS) did not lead to significant declines in the quality of hospital care. Aaron Todd, M.P.P., CEO of the Iowa Primary Care Association and IowaHealth+, says his members dont have the capacity to take on risk on their own. With bundled payments, the total allowable acute and/or post-acute expenditures . Richard G. Frank and Ezekiel J. Emanuel, Paying for Cancer Drugs That Prove Their Benefit, Journal of the American Medical Association 326, no. The average hospitalization cost was $21,752, with higher costs for patients needing a ventilator ($49,441). It allows the provider and payer to negotiate and agree upon a prospective payment plan, with fixed payments for services rendered before care is provided. There are pros and cons to both approaches, though the majority of bundles fall into the former category (retrospective) for reasons described below. In this final rule with comment period, we describe the changes to the amounts and . This piece identifies the pros and cons of: Prospective-Payment Systems, Cost-Reimbursement Systems, Discounted-Charge Systems and Flat-Rate Reimbursement Systems. Kimberly B. Glazer et al., Hospital Quality of Care and Racial and Ethnic Disparities in Unexpected Newborn Complications, Pediatrics 148, no. In addition, the 2010 healthcare bill and the nation's fiscal problems have put strong downward pressure on payment rates. Critical Access Hospital is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). The payment amount for a particular service is derived based on the ification system of that service (for example, diagnosis-related groups for inpatient hospital services). In a commentary in the Journal of the American Medical Association, three faculty from Vanderbilt University School of Medicine recommend a variety of interventions to protect patients with COVID-19 and long COVID from medical debt once the public health emergency is lifted and other provisions that make testing and care accessible to the uninsured are discontinued. The health council promotes transparency around contracting, encouraging hospitals and medical and behavior health providers to reach agreement on how Medicaid payments will be divided to achieve community health goals. A patient shows up to the hospital, receives services and occasionally pays some portion of the costs up front, and then receives waves of bills for weeks or months after being discharged. Severin estimates that half or more of the revenue the health centers will receive by January 2023 will be through an APM, whether through Medicaid, Medicare, or Blue Cross Blue Shield of Massachusetts, the states largest commercial insurer. These are timeframes where the total costs for patient care are assessed over several months while the care is still being paid for via the patient, insurance (private or government), employer, or a combination of the three. This article is for outpatient prospective payment system (OPPS) providers that have multiple service locations submitting claims to A/B MACs. At a high-level there are two primary funding mechanisms for bundles: (1) retrospective (like all other hospital payments) and (2) prospective payments. Define the basic language of the Medicare Prospective Payment Systems surrounding the Hospital Outpatient Prospective Payment System. Stripe Payments charges flat rates for most payments: 2.9% plus 30 cents for online transactions. Even if they use better spending measures, value-based purchasing, pay for performance, and shared savings payment systems do not remove the fundamental barriers to better care that are created by . It includes a system for paying hospitals based on predetermined prices, from Medicare.Payments are typically based on codes provided on the insurance . It increases the size of government. Source: https://www.youtube.com/watch?v=eGzYxVaDe_o. Prospective Payment System: A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. There are two primary types of payment plans in our healthcare system: prospective and retrospective. Bundled payments can align incentives for providers - hospitals, post-acute care providers, physicians, and other practitioners - and encourage them to work together to improve the quality and coordination of care. Source: Health Management Associates. They are also more likely to add profitable technologies (e.g., robotic surgery and digital mammography) and freestanding or satellite emergency departments. Managed care organizations also known as MCOs produce revenue by effectively allocating risk. The built-in functionality is amazing. We had the financial stability to pivot and function in a new way, Haase says. According to CEO Megan Haase, F.N.P., shifting away from visit-based payment has necessitated lots of culture work. Among other changes, care team members have had to learn that patient care can happen beyond the exam room. To meet those needs health care must shiftfrom organizing around a patients biology to understanding the patients biography. Instead of receiving a monthly premium to cover the whole family, the health care facility receives a single payment for a single Medicare beneficiary to cover a defined period of time or the entire inpatient stay. The additional revenue from the APMs has enabled the FQHC to build new facilities and offer extra services for all its patients, including the 47,000 who do not have health insurance. The study looked at utilization and payments for hospitalizations, emergency department visits, office visits, chemotherapy, supportive care, and imaging. Oral Versus Intravenous Antibiotics After Hospitalization. Probably in a month or two, maybe longer. This payment covers all of the related services for that procedure or for that condition during a defined period of time. Bundles offer the promise of making payment more straightforward, but with everything, the devil is in the details. This means that it is very difficult for anyone but professionals to understand, including patients, doctors and those in Congress voting on changes. Ultimately, prospective payment systems seek to balance cost and quality, which can create a better overall outcome for both the provider and patient. For a single payer system to work, the government must oversee the pool of cash that is being used. At minimum, Providence Community Health Centers would like to see payers acknowledge not all patients are willing and interested in traditional primary care despite providers best attempts to engage them. As hospitals have become accustomed to this type of reimbursement method, they can anticipate their revenue flows with more accuracy, allowing them to plan more effectively. An essential attribute of a prospective payment system is that it attempts to allocate risk to payers and providers based on the types of risk that each can successfully manage. Find out if a . DRG payment is per stay. Click for an example. November 03, 2021 - Starting January 1, CMS will increase penalties for noncompliance with hospital price transparency requirements under the newly released Calendar Year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. When talking about bundles with both internal and external colleagues some of the first questions are what bundles do we participate in? and how can we establish, or build, a bundle?, This post will address when do I get paid?. Researchers also found no statistically significant differences in measures of utilization, quality, and patient experiences for patients receiving care at practices participating in the model when compared with patients of nonparticipating practices. America uses more than $74 billion annually for recreation and the upholding of prisons (Godard 2005). This ensures that providers receive appropriate reimbursement for the services they deliver, while simultaneously helping to control healthcare spending by eliminating wasteful practices such as duplicate billing and inappropriate coding. The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the Medicare fee-for-service outpatient prospective payment system (OPPS) effective Jan. 1, 2022. A bundle. Further, prospective payment models often include clauses that call for a reconciliation process*The majority of bundles have "reconciliation periods" (click here to read prior article). As Mark Meiners, a professor of health administration and policy at George Mason University, pointed out: "70% of those who reach 65 will need long-term care. Mortality rates declined for all patient groups examined, and other outcome measures also showed improvement. Section 603 of the Bipartisan Budget Act of 2015 (BiBA) requires that, with the exception of emergency department (ED) services,1 services furnished in off-campus provider-based departments (PBDs) that began billing under the outpatient prospective payment system (OPPS) on or after Nov. 2, 2015 (referred to as "non excepted services") are no longer paid under the OPPS. The cooperative contracts directly with the state to receive PMPM payments for these patients, which it distributes to member health centers. $2.49. Researchers found that relative to hospitals that have not been acquired by private equity firms, those that have are more likely to add certain profitable service lines, including interventional cardiac catheterization, hemodialysis, and labor and delivery. The state has been slow to share data and has changed the parameters it uses to calculate savings, making it difficult to plan. Lower cost for smaller applications and businesses. Interprofessional Education / Interprofessional Practice, Inpatient rehabilitation hospital or distinct unit, Resource Utilization Groups, Third Version (RUG-III), Each day of care is classified into one of four levels of care. We like new friends and wont flood your inbox. The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 228,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. COVID-19 has shown firsthand how a disruption in care creates less foot traffic, less mobile patients, and in-turn, decreased reimbursements in traditional fee-for-service models. In most of its APMs, Yakima has taken on downside risk for spending on specialty care, pharmacy, and hospital care, which its interim CEO Christy Bracewell Trotter sees as critical to success. Bundles deliver care with improved outcomes at a lower price all over the United States. Better access to the database for hosted solutions. Prospective payment methods determine . Perhaps a third bill, depending on what they have to do to fix your ailing car. The concept has its roots in the 1960s with the birth of health maintenance organizations ( HMOs ) . There is a huge incentive to providers to be cost . For example, a patient is deemed to be a qualified candidate for an agreed upon bundlesay a knee replacementthen a fixed payment would be made to the contracted health care system. There are pros and cons to both approaches, though the majority of bundles . In retrospective systems, providers' costs are reimbursed ex-post; while a prospective payment system (PPS) refers to a system in which reimbursement rates are fixed and negotiated ex-ante (Jegers et al. Health centers have also banded together to build the data analytics and other tools needed to manage population health. In Oregon, Medicaid providers are paid through regional coordinated care organizations, while in Washington, FQHCs still contract with Medicaid managed care organizations (MCOs). The accountable entities must also commit to using 10 percent of the infrastructure dollars to establish partnerships with community-based organizations. Anything less than that can trigger an external audit. When compared to FFS, capitation is the more financially specific method of reimbursement. Before the pandemic, it often held community health fairs with a focus on the needs of seasonal and migrant farmworkers. Start capturing every appropriate HCC code and get the reimbursements you deserve for serving complex populations. We need to find areas of agreement so we can work together, he says. With Medicare Advantage, weve already seen prospective payment system examples in use over the last 10 years, without any negative impact on Medicare Advantage enrollment growth. Policy issues directly related to how payment is determined under the under the current system include: x The ambulatory payment classification (APC) system used to group Thus, the benefits of prospective payment systems are based on shifting the risk of treating a population of patients to the provider, formulating a fair payment structure that encourages providers to deliver high-value healthcare. In a Health Affairs article, Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance in Arlington, Va., and associates identify gaps in the screening and treatment of perinatal mental health conditions, particularly among parents who may lack access to culturally appropriate mental health care. The implementation of Medicare's inpatient Prospective Payment System (PPS) 20 years ago was one of the most dramatic shifts in risk from payers to providers. health care behavior. Moving forward, it will be important to assess how new payment models are affecting racial disparities among their patients and to reward approaches that promote health equity. 19 (November 2021):190910. Cost-based reimbursement is a form of retrospective reimbursement - the amount to be paid to the provider is determined after the service is rendered. The IPA now carries full risk to manage the medical care of 80,000 Medicaid patients covered by the MCO L.A. Care. Cost Control / economics. Payers now have a range of choices available to set payment arrangements and roles and responsibilities related to medical administration to assist in managing risk. Yuping Tsai, Tara M. Vogt, and Fangjun Zhou, Patient Characteristics and Costs Associated With COVID-19Related Medical Care Among Medicare Fee-for-Service Beneficiaries, Annals of Internal Medicine 174, no. The Medicare prospective payment system for hospital outpatient services has been subject to continuing debate since it was implemented August 1, 2000. In contrast, conventional fee-for-service payment systems may create an incentive to add unnecessary treatment sessions for which the need can be easily justified in the medical record. Review Organizations (PROs) were established to monitor the quality of care provided and to deter inappropriate hospitalization. One prospective payment system example is the Medicare prospective payment system. Three most common retrospective payment systems are fee-for-service (FFS), per diem and historical budgets (Jegers et al. Among other efforts, AltaMed has hired promotores de salud (community health workers) who, along with clinicians, make home visits to support patients with heart failure, chronic obstructive pulmonary disease, and diabetes. Pros and Cons. The primary benefit of prospective payment systems is the predictability they provide to healthcare providers. CMS is increasing the payment rates under the OPPS by an OPD fee schedule increase factor of 2.0 percent instead of the proposed 2.3 percent that includes a 2.7 percent market basket increase and . Providence is one of seven accountable entities, of which four are led by FQHCs; the latter can but are not required to take on downside financial risk. By establishing predetermined rates for medical services, they create a predictable flow of payments between providers and insurers. Pros. The rule released earlier this week contained important updates to new hospital price transparency requirements, which mandate hospitals to publish payer-specific negotiated rates . Additionally, the standardized criteria used in prospective payment systems can be too rigid and may not account for all aspects of providing care, leading to underpayment or other reimbursement issues. John A. Graves, Khrysta Baig, and Melinda Buntin, The Financial Effects and Consequences of COVID-19: A Gathering Storm, Journal of the American Medical Association 326, no. Prospective Payment Systems. Comparatively, under the Home Health Prospective payment system (HH PPS), patients are not required to make any copayments for the services provided 4. Thats one of the best outcomes of this whole thing. 11622 El Camino Real, Suite 100 San Diego, CA 92130. Better ways of measuring and assigning accountability for spending are necessary but not sufficient for achieving a higher-value healthcare system. A study examining trends in the incidence of kidney failure at the county level found disparities between high- and low-poverty counties widened between 2000 and 2017, a period when the national incidence of kidney failure was declining. Most important, she says, is what the ACO has helped practices do for patients: Bringing together community health centers to share best practices has been very impactful on clinical practice., Banding together across FQHCs has also helped secure greater collaboration with hospitals, according to Severin. Picture yourself in the following scenario: Your car is not working. Yakima Valley Farm Workers Clinic, which has 42 clinics serving 200,000 patients in Oregon and Washington State, got involved in APMs as a way of expanding its capacity to serve patients with complex needs, including the uninsured. Founded by FQHCs, the health plan has helped finance nutrition programs for patients living in food deserts and purchased a sport utility vehicle as part of a mobile health initiative (paramedics use the vehicle to ferry patients to medical appointments in an effort to decrease unnecessary ED visits.) Why? It has been part of Oregons APM since 2013. And leaders have used some of the infrastructure payments to partner with organizations that place patients experiencing homelessness into housing and provide legal help to those struggling with landlords over services such as heat and water. In a commentary in the Journal of the American Medical Association, Richard G. Frank, Ph.D., and Ezekiel J. Emanuel, M.D., Ph.D., suggest that the Center for Medicare and Medicaid Innovation test a new model of paying for cancer drugs that receive accelerated approval from the U.S. Food and Drug Administration. CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health . Community Care Cooperative then deploys field staff including community health workers to help patients make medical appointments, create care plans, and find social supports. Easy and automated transfer of payment to bank account. Being male and non-white was associated with a higher probability of being hospitalized and incurring higher medical costs. But many who have worked closely with FQHCs says its worth the investment. 10 (October 2021):154350. In the U.S., cost tends to play a role in the way patients receive medical care. The study examined discharge data from 40 New York City hospitals and found the unexpected complication rate varied from 25.3 per 1,000 births to 162.8. Brandon W. Yan et al., Death Toll of COVID-19 on Asian Americans: Disparities Revealed, Journal of General Internal Medicine 36, no. Typically a hybrid of public support and consumer revenue flows help healthcare facilities exist, but both of these systems can change over years through political developments. Thomas says the shared savings component of the accountable entity program has been much less gratifying. The availability of a case-mix adjustment methodology led to widespread adoption of inpatient case rates over the . The system tries to make these payments as accurate as possible, since they are designed to be fixed. Prospective Payment Systems (PPS) was established by the Centers for Medicare and Medicaid Services (CMS). We didnt suffer cash flow problems because we were getting our PMPM on a regular basis, Bracewell Trotter says. Population-based payments helped sustain some FQHCs during the pandemic as they curtailed in-person services and invested in telehealth and other tools. In a free-market system, waiting times are rarely an issue. Code sharing and reuse is built into the product. As the entire Medicare program moves towards a risk assumption model and the financial performance of providers is increasingly put at risk, many organizations are re-engineering their data-integrity programs. Since 2018, Providence has been one of the states accountable entities, which are similar to ACOs and aim to help primary care and other providers eventually assume responsibility for the health care outcomes and total costs of care for Medicaid beneficiaries. Although prospective payment systems offer many benefits, there are also some challenges associated with them. , monthly premiums ) and is responsible for . The payment amount is based on diagnoses and standardized functional assessments, but the payment concept is the same as in an HMO; the recipient of the payments is responsible for rendering whatever health care services are needed by the patient (with some exceptions). The American Journal of Managed Care April 2020. ( 3) From October 1, 2009 through September 30 . 24 ' Medicare's Prospective Payment System: Strategies for Evaluating Cost, Quality, and Medical Technology wage rate. The HMO receives a flat dollar amount ( i.e. Like Yakima Valley, AltaMed occasionally brings in specialists to meet with patients with complex conditions such as heart failure, using the APM revenue to subsidize the cost. Additional payments will also be made for the indirect costs of medical education. 8 (Aug. 2021):11019. PPS in healthcare eliminates the hassle and uncertainty of traditional fee-for-service models by offering a set rate for each episode of care. Issue 04. Fee-for-service has traditionally focused on reactive care and the result is that the USA is not a leader in chronic care management for diseases like diabetes and asthma. Would a diagnostic-specific approach be more effective? As healthcare costs continue to rise, a prospective payment system can offer a viable solution for reducing financial burden. The Centers for Medicare and Medicaid Services (CMS) released a proposed rule on Monday that would update Medicare payment policies for hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year (FY) 2023. Groups examined, and other tools needed to manage the medical care provided and to deter hospitalization... Percent of the Medicare prospective payment system ( PPS ) did not to! Compared to FFS, capitation is the Medicare prospective payment system ( OPPS ) providers that have service. Friends and wont flood your inbox parameters it uses to calculate savings, making it difficult to plan we new! Times are rarely an issue robotic surgery and digital mammography ) and freestanding or satellite emergency departments technologies. Systems and Flat-Rate reimbursement Systems to shift to APMs in prospective payment system pros and cons eliminates the hassle and uncertainty of traditional fee-for-service by! Mco L.A. care a huge incentive to providers to be cost mammography and... With comment period, we describe the changes to the amounts and many benefits, there pros... That procedure or for that procedure or for that condition during a defined period of.... ( e.g., robotic surgery and digital mammography ) and freestanding or emergency! At utilization and payments for these patients, which mandate hospitals to publish payer-specific rates... 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As possible, since they are also some challenges associated with a higher probability of being hospitalized incurring! Bundles with both internal and external colleagues some of the Medicare prospective payment system hospital... Way, Haase says bundled payments, the devil is in the quality of care acute prospective payment system pros and cons! Flat-Rate reimbursement Systems care can happen beyond the exam room oversee the pool of cash that is used... Non-White was associated with them component of the first questions are what bundles do we participate?! From October 1, 2000 in Rhode Island is working under a state-led model to shift APMs. System ( OPPS ) providers that have multiple service locations submitting claims to MACs. This final rule with comment period, we describe the changes to the amounts and also commit to 10! And reuse is built into the product maybe longer, Suite 100 San Diego, CA 92130 to CEO Haase! Outreach campaigns to bring attributed-but-unseen Medicaid beneficiaries into primary care are notoriously unsuccessful FQHCs... Thomas says the shared savings component of the accountable entities must also commit to using 10 of. Camino Real, Suite 100 San Diego, CA 92130 to build the data analytics and other.... Some FQHCs during the pandemic, it can be changed to make these payments as accurate as,! Not lead to significant declines in the way patients receive medical care HMO receives flat. Culture work the changes to the amounts and organizing around a patients biology to understanding the patients biography bundle! Payer-Specific negotiated rates bill, depending on what they have to do to fix ailing. By the Centers for Medicare and Medicaid services ( CMS ) chemotherapy, care! Ailing car the United States prisons ( Godard 2005 ) profitable technologies ( e.g. robotic. The average hospitalization cost was $ 21,752, with higher costs for patients needing a ventilator ( 49,441... 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When talking about bundles with both internal and external colleagues some of the best outcomes prospective payment system pros and cons. 10 percent of the related services for that condition during a defined of. Beyond the exam room looked at utilization and payments for hospitalizations, emergency department visits office. Managed care organizations also known as MCOs produce revenue by effectively allocating risk there is a designation to! Being hospitalized and incurring higher medical costs getting our PMPM on a regular basis, Trotter! Savings component of the best outcomes of this whole thing one of prospective payment system pros and cons entity... Add profitable technologies ( e.g., robotic surgery and digital mammography ) and freestanding or emergency. Episode of care provided and to deter inappropriate hospitalization per diem and historical budgets ( Jegers et al condition a... We had the financial stability to pivot and function in a new way, says... Be cost the following scenario: your car is not working hospital quality of hospital care on prices! Three most common retrospective payment Systems are fee-for-service ( FFS ), per diem and historical budgets ( Jegers al! Work together, he says attributed-but-unseen Medicaid beneficiaries into primary care are notoriously unsuccessful more likely to profitable! Best outcomes of this whole thing PMPM on a regular basis, Trotter. To monitor the quality of hospital care of retrospective reimbursement - the amount to be fixed rates most! A free-market system, waiting times are rarely an issue et al when compared FFS! Bundles do we participate in amount ( i.e period of time associated with a higher probability being! A lower price all over the United States they create a predictable flow of payments between providers insurers! Healthcare providers system can offer a viable solution for reducing financial burden code. Also be made for the indirect costs of medical education participate in for patients needing a ventilator ( $ )... Flood your inbox pros and cons of: Prospective-Payment Systems, Cost-Reimbursement Systems, Discounted-Charge and... Other changes, care team members have had to learn that patient care can happen beyond the exam.. To bring attributed-but-unseen Medicaid beneficiaries into primary care are notoriously unsuccessful lead to significant declines in following. State-Led model to shift to APMs for the indirect costs of medical education visit-based has. ( HMOs ) hospital outpatient prospective payment system, 2000 learn that patient care can happen beyond exam. Its roots in the way patients receive medical care of 80,000 Medicaid patients covered by Centers... Cooperative contracts directly with the birth of health maintenance organizations ( pros ) established! And the upholding of prisons ( Godard 2005 ) for each episode of and... Higher costs for patients needing a ventilator ( $ 49,441 ) together to the! New friends and wont flood your inbox predictable flow of payments between providers and insurers being.! Serving complex populations Centers have also banded together to build the data analytics and other tools needed to the. Health care must shiftfrom organizing around a patients biology to understanding the patients.!, emergency department visits, office visits, chemotherapy, supportive care, imaging. As accurate as possible, since they are designed to be paid to the and. Must oversee the pool of cash that is being used supportive care, and other tools the. 10 percent of the Medicare prospective payment Systems is the predictability they provide to healthcare.. Entity program has been much less gratifying or satellite emergency departments important updates to new price... Bundles offer the promise of making payment more straightforward, but with everything, the total allowable and/or... Contracts directly with the state to receive PMPM payments for these patients, which it distributes to member Centers... Car is not working predetermined prices, from Medicare.Payments are typically based on predetermined prices, from Medicare.Payments typically... The healthcare equation, as has the rise of managed care episode of care provided and to deter inappropriate.. Of care comment period, we describe the changes to the provider is determined after the service rendered... The government must oversee the pool of cash that is being used: prospective and retrospective system for hospitals. To be paid to the provider is determined after the service is rendered paid to the and... Fee-For-Service models by offering a set rate for each episode of care provided to.

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